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Superb Microvascular Imaging of Retained Placenta with Placenta PICTURE OF THE MONTH Superb Microvascular Imaging of Retained Placenta with Placenta Accreta Spectrum Toshiyuki Hata1, Uiko Hanaoka2, Ayumi Mori3, Kenta Yamamoto4, Chiaki Tenkumo5, Nobuhiro Mori6, Kenji Kanenishi7, Hirokazu Tanaka8 ABSTRACT We present our first experience of using superb microvascular imaging (SMI) with an 18-MHz linear probe to diagnose placenta accreta spectrum (PAS) in the retained placenta after vaginal delivery. In the first case, irregular minimal invasion of the retained placenta into the anterior myometrium and a thin uterine wall were clearly noted. In the second case, SMI clearly demonstrated the loss of myometrium anterior to fundal lesions and abnormally dilated, torturous, stem villous vessels invading until the uterine serosa. SMI with the use of an 18-MHz linear probe may be a novel diagnostic tool for the diagnosis of PAS in the retained placenta after delivery. Keywords: 18-MHz linear probe, High-resolution ultrasound, Placenta accreta spectrum, Retained placenta, Superb microvascular imaging. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2019): 10.5005/jp-journals-10009-1600 INTRODUCTION 1–8 Department of Perinatology and Gynecology, Kagawa University A placenta accreta spectrum (PAS) is one of the most serious and Graduate School of Medicine, Miki, Kagawa, Japan potentially life-threatening conditions for both a pregnant woman 1 Corresponding Author: Toshiyuki Hata, Department of Perinatology and fetus. The precise prenatal diagnosis of PAS improves the and Gynecology, Kagawa University Graduate School of Medicine, prognosis of the patient and reduces maternal morbidity.2 The Miki, Kagawa, Japan, Phone: +81-87-891-2174, e-mail: toshi28@med. European Working Group on PAS has proposed standardized kagawa-u.ac.jp 3 ultrasound descriptors of this spectrum. However, the heterogeneity How to cite this article: Hata T, Hanaoka U, et al. Superb Microvascular in terminology and differences in study design limit the assessment Imaging of Retained Placenta with Placenta Accreta Spectrum. Donald of the accuracy of ultrasound imaging in the screening and diagnosis School J Ultrasound Obstet Gynecol 2019;13(3):85–87. 4 of PAS. Therefore, standardized protocols for screening, diagnosis, Source of support: Nil 5 and management of PAS need to be developed. Conflict of interest: None Superb microvascular imaging (SMI) is the latest Doppler technology, and it can detect lower blood flow velocity without motion artifacts.6, 7 Moreover, SMI provides high-resolution ultrasound Case 2 images at high frame rates. There have been only three SMI studies on A 40-year-old Japanese woman spontaneously aborted in our 8–10 normal and abnormal placental vasculatures. Moreover, there has university hospital at 18 weeks and 6 days of gestation. She been only one report to diagnose PAS with SMI using an 18–24 MHz had undergone enucleation of uterine adenomyosis at another 11 probe during pregnancy. Here, we present our first experience of hospital 20 months previously. After she delivered, the placenta using conventional SMI and high-resolution SMI with an 18-MHz remained in situ. Two-dimensional sonography showed broad linear probe to diagnose PAS in the retained placenta after delivery. anechoic lesions in the uterus, and conventional SMI revealed abundant blood flow in the placental bed adjacent to the uterine CASE DESCRIPTION wall (Fig. 3). MRI suggested placenta increta (placental invasion to Case 1 the anterior myometrium and thinner uterine wall at the anterior A 37-year-old Japanese woman was referred to our university fundal lesion). High-resolution SMI with an 18-MHz probe clearly hospital because of retained placenta and excessive postpartum demonstrated the loss of myometrium anterior to fundal lesions bleeding after delivery. Two-dimensional (2D) sonography and and abnormally dilated, torturous, stem villous vessels invading conventional SMI (Aplio i800, Canon Medical Systems, Tokyo, Japan) until the uterine serosa (snow storm-like appearance) (Fig. 4). There showed suspicious signs of PAS at the anterior uterine wall (Fig. 1). was no excessive vaginal bleeding. The placenta was left in situ , and MRI could not clearly demonstrate the PAS. High-resolution SMI with the patient was discharged without any adverse events. The patient an 18-MHz linear probe clearly depicted irregular minimal invasion is now scheduled for monthly scans until the placenta has been of the retained placenta into the anterior myometrium, and a thin completely reabsorbed. uterine wall was noted (Fig. 2A). High-resolution SMI also revealed disruption of decidual vessels (DV) at this pathological lesion, and DISCUSSION abnormal lacunar flow was also noted (Fig. 2B). Ultrasound-guided Retained placenta after vaginal delivery is a rare complication removal under general anesthesia was performed, and removal associated with increasing maternal morbidity and mortality.12 of the placenta was successful. Histopathological diagnosis of the Common causes of retained placenta are PAS. However, there is removed placenta was placenta accreta (the villi attached directly no consensus concerning acceptable interobserver variability of to the myometrial tissue without intermediate decidua). ultrasound signs.13 One possible explanation for the inconsistent © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons. org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. SMI of Retained Placenta with Placenta Accreta Spectrum Figs 1A and B: Retained placenta with placenta accreta. Two-dimensional sonography (A) and conventional SMI (B) show suspicious signs of PAS at the anterior uterine wall (arrow). M, myometrium; MASF, maternal abdominal subcutaneous fat; P, placenta Figs 2A and B: Retained placenta with placenta accreta. High-resolution ultrasound with an 18-MHz linear probe clearly demonstrates irregular minimal invasion of the retained placenta into the anterior myometrium (arrows), and a thin uterine wall is noted (A). Superb microvascular imaging with an 18-MHz linear probe reveals a minimally invasive placenta in the anterior myometrium (arrows) and the disruption of DV (B). Abnormal lacunar flow is also noted. M, myometrium; MAM, maternal abdominal muscle; MASF, maternal abdominal subcutaneous fat; P, placenta diagnostic criteria is the low resolution of conventional sonographic probes. Moreover, many of the ultrasound signs for the diagnosis of PAS are indirect findings.3 In the present study, we used high- resolution SMI with an 18-MHz transabdominal probe and obtained the direct findings of irregular minimal invasion of the retained placenta into the anterior myometrium in the first case. In the second case, the loss of myometrium anterior to fundal lesions was clearly visualized. Moreover, this technique clearly showed the disruption of DV and abnormal lacunar flow in the placenta of the first case, and abnormally dilated, torturous, stem villous vessels (snow storm-like appearance) invading until the uterine serosa were evident in the second case. In the previous investigation on the antenatal diagnosis of PAS using high-resolution SMI with an Figs 3A and B: Retained placenta with placenta increta/percreta. Two- 18–24 MHz probe, unique characteristic of PAS was dilated stem dimensional sonography shows broad anechoic lesions in the uterus 11 villous vessels at the lesion of placenta increta. These results (arrows) (A), and conventional SMI reveals abundant blood flow in the suggest that high-resolution SMI using an 18-MHz probe may also placental bed adjacent to the uterine wall (B). P, placenta 86 Donald School Journal of Ultrasound in Obstetrics and Gynecology, Volume 13 Issue 3 (July–September 2019) SMI of Retained Placenta with Placenta Accreta Spectrum Figs 4A to C: Retained placenta with placenta increta/percreta. High-resolution ultrasound (A) and SMI (B and C) with an 18-MHz probe clearly demonstrate the loss of myometrium anterior to fundal lesions. Two-dimensional sonography depicts abnormally dilated, torturous vessels (A). Abnormally torturous, abundant blood flow (snow storm-like appearance) invading until the uterine serosa is evident (B). Abnormally dilated stem villous vessels (STV) are also evident (C). MAM, maternal abdominal muscle; MASF, maternal abdominal subcutaneous fat; P, placenta be a novel diagnostic modality for the precise diagnosis of PAS in imaging. Am J Obstet Gynecol 2018;218:75–87. DOI: 10.1016/j.ajog. the retained placenta after delivery. Further studies involving a lager 2017.05.067. sample size are needed to clarify the usefulness of high-resolution 6. Wu L, Yen HH, et al. Spoke-wheel sign of focal nodular hyperplasia SMI with an 18-MHz probe in the correct diagnosis of PAS during revealed by superb micro-vascular ultrasound imaging. QJM 2015;108:669–670. DOI: 10.1093/qjmed/hcv016. or after delivery. 7. Ma Y, Li G, et al. The diagnostic value of superb microvascular imaging (SMI) in detecting blood flow signals of breast lesions. Medicine (Baltimore) 2015;94(36):e1502. DOI:
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